The Anaesthesilogist is Senior staff trained on such procedure.
Pre-operative settings
The study subjects will randomly assigned to 3 equal groups (TAP group, infiltration
group and narcotics only group ) using a computer-generated table of random numbers. A
single investigator will assess the patients for eligibility, obtained written informed
consent, and record the baseline data for each participant before delivery. Sequentially
numbered, sealed opaque envelopes containing group allocation will be opened by the
primary investigator after administration of general anesthesia . Neither the study
subjects nor the outcome assessors knew the study group
Routine preoperative investigations will be done to all patients including laboratory
investigations as (complete blood picture, liver function tests, prothrombin time and
partial thromboplastin time).
Demographic data as age, weight, will be recorded.
All mothers who scheduled for elective cesarean delivery who fulfilled inclusion criteria and
volunteer are assessed by:
Postoperative pain by Numerical Rating Scale (NRS) pain score (range, 0-10; 0, no pain; 10,
worst pain) on arrival in the post-labor ward (time 0) and at 2,4,6, 8, 12,18 and 24 hours
postoperatively.
The duration of block (defined as the interval between performing the block and the time of
the first request for analgesia) and total pethidine consumption were recorded in the 24
hours after surgery The level of patient satisfaction was measured numerically by a Likert
scale ranging from one to five, 1: "not satisfied at all," 2: "slightly satisfied," 3:
"moderately satisfied," 4: "very satisfied," and 5: "highly satisfied". Any adverse effects
or complications will be recorded.
Wide bore venous access will be secured by 18 G intravenous canula
The procedure is done in the operating rooms (OR) under complete aseptic technique with
prophylactic antibiotics (e.g. 2 gm ceftriaxone).
Intra-operative Setting
The patient will be monitored during the procedure using pulse oximetry, non-invasive
blood pressure & ECG and capnography
Patients receive General anesthesia induction by propofol (2mg/kg),Rocuronium(0.5mg /kg)
for rapid sequence intubation& Fentanyl (1 mcg /kg)
Maintenance with rocuronium & isoflurane 1.2%
Equipment's that will be used for each patient are:
Sterile towels, sponges, 4-inch gauze packs and povidone iodine 10% for sterilization
Sterile gloves, marking pen, 18-gauge cannula and 10-ml syringes containing drugs for
administration of the procedure.Ultrasound device with Linear probe with high frequency
(6 -13 MHz) will be used in imaging of patient
drugs that will be used In our study are: A 20 ml vial of 0.5% Bupivacaine HCl ,
pethidine IV (50-150 mg)
Lower segment cesarean section will be performed using the Pfannenstiel incision
An anesthesiology resident will administer the general anesthesia, will record the
intraoperative data (the duration of surgery), and prepared, as instructed by the
primary investigator , the local anesthetic solution for the TAP block and wound
infiltration. The outcome data (pethidine consumption, time to the first pethidine dose,
pain scores level , side effects, and patient satisfaction) will be recorded by a blind
investigator who will visite the patient in the ward at 2, 4, 6, 12, and 24 hours
postoperatively.
Group A: TAB group formed of 65 patients
After completion of LSCS and skin closure and while the patient is still on the
operating table U/S guided TAP block will be done using the following procedure:
After preparing the skin with antiseptic solution, a linear high frequency ultrasound
probe (Superficial probe of mindray DP-20) will be placed transversely on the
anterolateral abdominal wall between the iliac crest and the costal margin. Under US
guidance, the three layers of muscles -external oblique, the internal oblique, and the
transversus abdominis will be identified. A Spinal needle 22g attached with flexible
tubing to a syringe filled with saline will be used to perform the block. The needle
will be then introduced through the skin anteriorly in the plane of the ultrasound beam
and advanced into the fascial plane between the internal oblique and transversus
abdominis muscles with its tip lying in the mid axillary line. To assist with
identifying these structures, the probe will be moved anteriorly to the rectus sheath
and the fascial planes followed laterally. The final position of the probe will to be no
further anterior than the anterior axillary line. If satisfactory views are not
obtained, the TAP block will not be performed. Hydro dissection with saline (2-5 ml)
will be used to separate the fascial layers. After aspiration to exclude inadvertent
vascular puncture, a test dose of 1-2 ml of the drug will be injected to confirm needle
placement. After a negative test dose, 20 ml of the 0.25% bupivacaine will be injected
while closely observing for signs of toxicity e.g CVS toxicity which may be in form of
early features e.g hypertension, tachycardia and ventricular arrhythmia or may be in
form of late features e.g hypotension, bradycardia, heart block and decreased
contractility and other toxic signs e.g tinnitus, perioral numbness, metallic taste in
mouth, slurring of speech and mental status changes). TAP block will be performed in a
similar fashion on the opposite side.
Group B : The Infiltration Group formed of 65 patients.
• This group will B wills provided with single-shot local anesthetic wound infiltration with
20 ml of 0.25% bupivacaine injected subcutaneously above and below skin incision before
closure of skin.
Group C : Narcotics only group formed of 20 patients • routine analgesic was taken only
without any intervention
Post operative settings:
At the end of the surgery and complete recovery from anesthesia, the patient will be
kept under observation postoperatively for 4 hours to monitor vital signs (conscious
level, blood pressure, heart rate, respiratory rate and pattern & any possible limb
weakness or abnormal sensation) then discharged to ward & observed to be followed for
returning of pain.
Duration of surgery (time from the start of skin incision to the end of skin closure)
will be recorded. All the study subjects will receive postoperative standard analgesia
(30 mg of IV ketorolac every 8 hours starting immediately after surgery and 1 gm of oral
paracetamol every 6 hours starting 4 hours after surgery with caution to toxic dose) .
The patients will be observed for the occurrence of any adverse effect and/or
complication related to the procedure (e.g. hematoma), or to the study drugs (e.g.
hypotension/hypertension (i.e. 20% decrease or increase from the baseline value),
bradycardia (HR <50 beats/min) or tachycardia (HR > 120 beats/min), nausea, vomiting,
and hypoxemia (SpO2 <90%)).
Assessment of pain involves asking a patient to rate her pain from 0 to 10 (11 point
scale) with the understanding that 0 is equal to no pain and 10 equal to the worst
possible pain after first hour, 2nd hour,4th hour, 6th hour, 12th hour and 24th hour at
wards after end of surgery.
Pain is usually managed by pethidine IV based on patient complain. the analgesic dose of
pethidine will be 50 mg to be repeated on demand (NRS >4) provided that the total 24 hour
dosage will not exceed 150 mg . At recovery room mothers asked to report their pain based on
11 point NRS score during first 24 hour. Patient satisfaction from postoperative analgesia
will be assessed at 24 hours postoperatively using a 5-point scale (1 = very unsatisfied, 2 =
unsatisfied, 3 = fair, 4 = satisfied,and 5 = very satisfied) after first hour, 2nd hour,4th
hour, 6th hour, 12th hour and 24th hour at wards after end of surgery.
• A time in minutes from end of surgery to first analgesia request were documented together
with total analgesia consumed in the first 24 h. In addition, incidence of postoperative
nausea and vomiting will be documented within 24 h.